Stellate ganglion

Intra-arterial injection of thiopentone is a serious complication as crystals of the thiobarbiturate can form in the arterioles and capillaries, causing intense pain, vasoconstriction, thrombosis, and even tissue necrosis. Accidental intra-arterial injections should be treated promptly with intra-arterial administration of a vasodilator (papaverine 20 mg) and lignocaine (lidocaine) Note leave the needle/cannula in the artery), as well as a regional anaesthesia-induced sympathectomy (stellate ganglion block, brachial plexus block) and anticoagulation with intravenous heparin. The risk of ischaemic damage is much higher with a 5% solution and the use of this concentration is not recommended. 

The preganglionic (second-order) neuron is located in the chest and neck extending from the cervical cord (C8-T2) through the stellate ganglion at the pulmonary apex to the superior cervical ganglion at the bifurcation of the internal and external carotid arteries. 

Acute and Postherpetic Neuralgia. In addition to antivirals, oral analgesics are recommended for pain. If the pain is severe, an opioid analgesic may be prescribed. A stellate ganglion block, administered by an anesthesiologist within 14 days of the rash, may also be helpful. 

Brachial plexus anesthesia Buccal anesthesia Caudal anesthesia Cervical plexus anesthesia Dental anesthesia Digital anesthesia Epidural anesthesia Intercostal nerve anesthesia Interpleural anesthesia Intra-articular anesthesia Intradermal anesthesia Intrathecal (spinal) anesthesia Intravenous regional anesthesia Laryngeal anesthesia Lumbar plexus anesthesia Nasal anesthesia Neck anesthesia Obstetric anesthesia Ocular anesthesia Oropharyngeal anesthesia Otic anesthesia Paravertebral anesthesia Perianal anesthesia Peritonsillar anesthesia Respiratory anesthesia Sciatic nerve anesthesia Stellate ganglion anesthesia... 

Cardiovascular complications can arise from unintended stellate ganglion block (SEDA-21,131). 

Horner s syndrome is a well-recognized complication of interscalene brachial plexus block, stellate ganglion block, and occasionally epidural blockade. It occurs when the local anesthetic reaches the cervical sympathetic trunk and is usually transient. However, persistent Horner s syndrome is a rare complication, and may represent traumatic interruption of the cervical sympathetic chain. Cases of prolonged Horner s syndrome related to prevertebral hematoma formation at the site of continuous interscalene blockade have been described (66). 

Inadvertent spinal anesthesia and subsequent nervous system toxicity, for example with transient paralysis or apnea, are the main complications of stellate ganglion block (SEDA-22, 140). It has been suggested that ultrasound guidance when performing the block might improve safety (357). The use of very small test doses and an anterior approach to the stellate ganglion are recommended preventive measures. 

In two women with Raynaud s syndrome, the symptoms were aggravated contralaterally after stellate ganglion block (SEDA-18,145). 

Convulsions are a recognized complication of inadvertent intra-arterial injection during stellate ganglion block two such cases have been described (360). 

A 28-year-old 75 kg woman underwent stellate ganglion block for symptomatic treatment of Raynaud s syndrome. An anterolateral approach was used, guarding the carotid artery and jugular vein. After an aspiration test was negative in two planes, 5 ml of 1% lidocaine was injected over 2-3 seconds using a 20 G needle. However, a second aspiration test was positive for blood, the needle was pulled back, and on reinjection the patient immediately had a severe generalized tonic-clonic seizure. The patient made a rapid recovery with no further treatment and was fully conscious after 2 minutes. 

Omote K, Kawamata M, Namiki A. Adverse effects of stellate ganglion block on Raynaud s phenomenon associated with progressive systemic sclerosis. Anesth Analg 1993 77(5) 1057-60. 

Mahli A, Coskun D, Akcali DT. Aetiology of convulsions due to stellate ganglion block a review and report of two cases. Eur J Anaesthesiol 2002 19(5) 376-80. 

In a case of quinine poisoning, stellate ganglion block was performed immediately on the basis of the clinical history of visual disturbance without waiting for physical signs to develop. There was no residual field defect despite the presence of toxic concentrations of the drug. The authors suggested that stellate ganglion block may prevent development of visual field defects due to quinine toxicity (13). However, in other cases it was ineffective (14,15). The effectiveness of this treatment may be a function of the speed with which it is instituted. 

Boscoe MJ, Calver DM, Keyte C, Ayres JG. Quinine overdose. Prevention of visual damage by stellate ganglion block. Anaesthesia 1983 38(7) 669-71. 

It has been suggested that the vasodilation observed on stimulation of sympathetic fibers is a result of a sympathetic cholinergic innervation. In a recent study, Feigl stimulated the stellate ganglion and hypothalamus and found no evidence of cholinergic mediated coronary vasodilation. Information obtained by sympathetic stimulation of the coronary circulation has been recently criticized. The distribution of alpha and beta receptors within the coronary vasculature may vary with species and physiological state of the animal. Different experimental approaches may favor stimulation of either alpha or beta receptors. Other factors may be involved such as dose or time dependent actions of catecholamines on different receptors. 

Neural components that participate in the regulation of coronary blood flow include the sympathetic nervous system, the parasympathetic nervous system, coronary reflexes, and possibly, central control of coronary blood flow. Within the sympathetic system, stimulation of the stellate ganglion elicits coronary vasodilation, which is associated with tachycardia and enhanced contractility. This indirect coronary vasodilation is secondary to increased MVO2 related to increased heart rate, contractihty, and aortic pressure and occurs following stellate stimulation. The direct effect of the sympathetic system is a 1-mediated vasoconstriction at rest and during exercise. Other receptor types, 2 and have little influence on tone, whereas /32-stimulation produces a modest vasodUatory effect. Although coronary atherosclerosis may decrease blood flow secondary to obstruction, severe coronary atherosclerosis and obstruction also may increase the sensitivity of coronary arteries to the effects of aj-stimulation and vasoconstriction. 

Gilbert R, Ryan JS, Horackova M, Smith EM, Kelly ME (1998) Actions of substance P on membrane potential and ionic currents in guinea pig stellate ganglion neurons. Am J Physiol 274 C892-C903... 

The authors proposed that Homer s syndrome can result if sympathetic blockade extends upwards to involve the stellate ganglion. The brachial plexus palsy was explained by the fact that the stellate ganglion is in close proximity to the C7-T1 nerve roots feeding into the brachial plexus. Knowledge of the anatomy can prevent unnecessary imaging and anxiety, and simple discontinuation is sufficient treatment. 

Erickson SJ, Hogan QH (1993) CT-guided injection of the stellate ganglion description of technique and efficacy of sympathetic blockade. Radiology 188 707-709... 

Haaga JR et al (1984) Improved technique for CT-guided celiac ganglia block. AJR 142 1201-1204 Harding SP et al (1986) Relief of acute pain in herpes zoster ophthalmicus by stellate ganglion block. Br Med J 292 1428... 

Stellate ganglion block, Lumbar sympathectomy. Peripheral nerve block... 

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